384001605-7-28-2025-05-CC-CQUO-DJZTZS-20250728151049

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384001605
Report Date: 07/28/2025
Date Signed: 07/28/2025 03:10:58 PM

Document Has Been Signed on 07/28/2025 03:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	FORDE, KELLY E.		FACILITY NUMBER:	384001605
ADMINISTRATOR/ DIRECTOR:	FORDE, KELLY E.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 641-4123
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94131
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 12	CENSUS: 12	DATE:	07/28/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Kelly Forde		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On July 28, 2025 at approximately 1:30pm, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with licensee, Kelly Forde, and explained the purpose of the visit. Present during LPA's visit included licensee, teacher, and 12 preschool children. Licensee is operating within capacity limits and ratio during LPA's visit. Licensee lives in the multi-level home with their spouse, adult child and minor child. All adults living in the home have fingerprint clearance on file. Hours of operation are Monday through Friday 8:00am to 5:00pm. Main entrance to family child care home is located on the ground level door. Licensing documents are posted in hallway of main entrance to family child care home. The home consists of three levels. The family childcare operates on the second level of the home. The DAY CARE AREAS are the entire second level of home (except bedroom #1 and bathroom next to kitchen) and backyard. The OFF LIMIT AREAS are the ground level of the home (pass through only), entire third level of the home, bathroom next to kitchen (second level) and bedroom #1 (second level). There are stairs inside and outside the home that are made inaccessible with a closed door or child, safety gate. LPA inspected day care areas for health and safety hazards. LPA observed home to be clean and organized. Day care areas are equipped with a variety of toys, materials and equipment that are age appropriate and clean. Per teacher present, toys and materials are sanitized weekly and daily, if needed. Flooring in day care areas are observed to be clean and in good condition. LPA observed toys and materials in day care areas to be stored appropriately, when not in use. LPA also observed knives in kitchen to be in accessible to children, stored in a high magnetic strip on wall. (Continue Report on Page 2...)

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Catrina Quimbo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FORDE, KELLY E.	FACILITY NUMBER: 384001605
	VISIT DATE: 07/28/2025

NARRATIVE

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LPA observed cleaning solutions and poisons to be stored in home's high shelves, inaccessible to children. Food service is provided by licensee that includes two snacks and a lunch. Reusable dishes are utilized for children that are sanitized daily in home's dishwasher.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Bathroom for children's use was observed to be in working condition and equipped with age appropriate toileting equipment. Children's families provide diapers and wipes. LPA observed home to have multiple garbage bins with tight fitting lids.

Preschool children sleep on both cots and pack and play cribs. Per teacher, preschool children sleep in cribs depending on the development of the child. Sheets and blankets are provided by licensee and are laundered weekly or as needed. Licensee stated they are aware sleeping regulations are for infants (under 24 months).

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Backyard is fully fenced and enclosed. Backyard includes a variety of toys and equipment that are in good condition. LPA observed stairs in backyard to be barricaded with a child safety gate. There is an outdoor play structure in the backyard. LPA did not observe any pools, spas or bodies of water on site.
(Continue Report on Page 3...)

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Catrina Quimbo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FORDE, KELLY E.	FACILITY NUMBER: 384001605
	VISIT DATE: 07/28/2025

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LPA observed home to be equipped with a fire extinguisher, multiple first aid kits, smoke detector and carbon monoxide detector.

A childcare roster is maintained and was made available for LPA's review. Emergency disaster drills are conducted and are appropriately documented. Last disaster drill was conducted 7/16/2025. Per licensee, there are no weapons or firearms in the home.

LPA reviewed facility records that included all enrolled children's records, licensee's record and teacher's record. Children's records are complete. LPA observed licensee and teacher's CPR and First Aid certification to have expired earlier this year. Licensee stated they will renew their CPR certification as soon as possible.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at
www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the licensee, Kelly Forde, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Type B citation was issued for licensee's expired CPR certification. A plan of correction was discussed. Appeal rights were provided. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Kelly Forde.

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Catrina Quimbo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/28/2025 03:10 PM - It Cannot Be Edited

Created By: Catrina Quimbo On 07/28/2025 at 02:45 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FORDE, KELLY E.	FACILITY NUMBER: 384001605
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee's CPR certification has expired as of 01/2025, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2025
	Plan of Correction
1 2 3 4	Licensee stated they will renew their CPR certification as soon as possible. LPA reminded licensee CPR must be Emergency Medical Services Authority (EMSA) certified. Proof of licensee's renewed certification will be provided to LPA no later than the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Marie Rodriguez
NAME OF LICENSING PROGRAM MANAGER:

	Catrina Quimbo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025

LIC809 (FAS) - (06/04)

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